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MEDICAL DOCUMENTATION AND REPORT WRITING

Category: EMS Operations

Topic: Documentation

Level: EMT

16 minute read

The prehospital care report or PCR (also ePCR when in the electronic format) serves as the only record of each individual patient contact, treatment, transportation, or cancellation of services within each EMS service.

CONTINUITY OF CARE: The PCR, when completed accurately and fully detailed, is used for continuity of care between EMS and the destination facility, for administrative services such as billing, and can also be utilized as a legal document in courts of law proceedings.

PCR: 

  • Each PCR should include all pertinent times associated with the EMS call.
  • As well as the times of the assessments and treatments provided, the PCR should include detailed signs and symptoms and other assessment findings such as vital signs, and all the specific emergency care provided. 
  • Also documented are changes in patient condition after treatment.
  • Any pertinent observations from the scene may be important for patient care or for legal purposes, requiring detailed recording in the PCR with the notion of future use.
  • The patient disposition is also recorded, including who patient care was turned over to (usually a nurse at a receiving hospital) or a patient refusal.

 

Report Writing

Patient care reports should include what is known as a minimum data set, or the absolute least amount of information possible, to facilitate correct tracking of EMS data by the National EMS Information System.

MINIMUM DATA SET: two separate types of data that are recorded,

1. PATIENT INFORMATION:

  • chief complaint,
  • the initial assessment,
  • vital signs, and
  • patient demographics.

  

2. ADMINISTRATIVE INFORMATION:

  • the time the incident was reported,
  • the time the responding unit was notified,
  • the time of arrival at the patient,
  • the time the unit left the scene,
  • the time of arrival at the destination, and
  • the time of transfer of care.

All times being required mandates accurate and synchronous clocks across the entire EMS system

SOAP NOTE:Traditionally, the SOAP method is used for narrative documentation and includes all pertinent information. SOAP is an acronym for a patient care report that includes:

  • Subjective: details relative to the patient's experience of the illness or injury like onset time, history, complaint, etc.
  • Objective: data that can be verified or observed by multiple people and get the same results, such as vital signs, lab values, and physical exam findings.
  • Assessment: analysis of the problem based on subjective and objective data.
  • Plan: the treatment that should be carried out in the best interest of the patient.

ERROR CORRECTION: Errors discovered while the report form is being hand-written should be corrected by drawing a single horizontal line through the error, initialing it, and writing the correct information beside it.

â–º EMS professionals should never attempt to obliterate the error because this could be interpreted as an attempt to cover up a mistake.

Errors discovered after a handwritten report form is submitted should be corrected, preferably with different color ink, by drawing a single line through the error, initialing and dating it, and the addition of a note with the correct information. If information was omitted, a note should be added with the correct information, the date, and the initials of the EMS professional.

Errors discovered while/after completing an electronic patient care report should be corrected within the ePCR system when possible, through the amendment or addendum portion of the program used.

If there is no way to electronically submit a change or addendum, and EMS professional should follow the correction method used for a handwritten report that has already been submitted on the printout of the electronic report.

 

Judging vs Judgment

Don't judge. 

Example: Don't write that the patient was "drunk." However, you should report slurred speech, smell of alcohol on his/her breath, and lack of coordination. You should also document in quotes any statements/confession, e.g., "I am so wasted!" THEN, use judgment for how to proceed, based on the objective findings/documentation. 

 

Documenting Patient Refusals

Competent adults always have the right to refuse medical treatment.

In the instance that a patient is attempting to refuse treatment or transport by Emergency Medical Services, an EMS professional should ensure the patient is able to make a rational, informed decision.

  • EMS should inform the patient why he/she should go and
  • what may happen to him/her if he/she does not.

Keep in mind that online medical control can be consulted as per local protocol. If the patient still refuses, the EMS professional should thoroughly document any assessment.

  • A signature of a witness to a patient refusal is always recommended, preferably a family member, police officer, or bystander.

If the patient refuses to sign the refusal form, have a family member, police officer, or bystander sign the form verifying that the patient refused to sign--as well as refused treatment/transport.

The patient care report should still be completed and should include a complete patient assessment (as complete as was performed), as well as documentation supporting the refusal of care and/or complete assessment.

  • Documentation should include any care or treatment plan the EMS professional wished to provide for the patient, and the statement that the EMS professional explained to the patient detailing possible consequences of failure to accept care, up to and including potential death.
  • The EMS professional should always offer alternative methods of gaining medical care for the patient and state the willingness of EMS to return to treat and transport the patient if he/she were to have a change of mind.
  • Before an EMS professional leaves the scene, he/she should try again to persuade the patient to go to the hospital.
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